NCLEX-RN
Practice NCLEX RN Test Questions
Extract:
Question 1 of 5
The physician has made a diagnosis of 'shaken child' syndrome for a 13-month-old who was brought to the emergency room after a reported fall from his highchair. Which finding supports the diagnosis of 'shaken child' syndrome?
Correct Answer: C
Rationale: Retinal hemorrhages are a hallmark of shaken baby syndrome due to the shearing forces from violent shaking causing bleeding in the retina.
Question 2 of 5
The nurse is caring for a laboring client who is on an oxytocin infusion. The client experiences seven contractions in a 10-minute time period. The fetal heart rate tracing is a category III. Which action should the nurse take?
Correct Answer: A
Rationale: A category III fetal heart rate tracing indicates fetal distress, and seven contractions in 10 minutes suggest uterine hyperstimulation. Discontinuing oxytocin is the priority to reduce fetal stress.
Question 3 of 5
The nurse is caring for a client receiving IV vancomycin. The trough level is 14 mcg/mL. The next dose is now due. What is the correct response by the nurse?
Correct Answer: A
Rationale: A vancomycin trough of 14 mcg/mL is within the therapeutic range (10-20 mcg/mL), so the next dose can be given as ordered.
Question 4 of 5
A 3-year-old is immobilized in a hip spica cast. Which discharge instruction should be given to the parents?
Correct Answer: D
Rationale: Tucking a diaper beneath the cast at the perineal opening helps keep the cast clean and prevents skin irritation.
Question 5 of 5
A nurse is caring for a 37-year-old woman with metastatic ovarian cancer admitted for nausea and vomiting. The physician orders total parenteral nutrition (TPN), a nutritional consult, and diet recall. Which of the following is the BEST indication that the patient’s nutritional status has improved after 4 days?
Correct Answer: C
Rationale: albumin levels are best indicators of long-term nutritional status